12077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING • APPLICATION & PERMIT
ADDRESS 1 pS W-R. 12 0 7 7
B ILDING-ELECTRICAL-PLUMBING-MECHANICAL
t OWNER's PLAN CHECK VALIDATION
NAME ELECTRIC PERMIT FEE
PHONE
NAMEA R �� O TLETS-SWITCHES-RECEP 10.00/1.00
N LIGHTING FIXTURES 10.00/1.00
CONT.ACYIDR's pp /�� APPLIANCES-RESIDENTIAL 4.00
AODRES y\r p'
x \ , PHDN All) PANELS 10.00 DATE OF APPLICATION
ogcHlT cT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER LIC NO. SIGNS TRANS. ` 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00 _ n
ADDRESS MOTORS SEE FEE SCH. '
AS
SERVICE CHANGE 20.00
00 LICENSED CONTRACTORS DECLARATION
u w I hereby affirm that I am licensed under provisions of Chapter'I ISSUANCE DATE
mz (commencing on O 7000)of Division,3 of the Bpsin and BLDG. .ELECT. PLG. MECH.
i Professions Cod a d c se is iii be o e dleffrfCy/l ❑ ❑ ❑
Z 0 w - License Class Lic.Number I G -
W w H w Dafe� IVRER actor
W IS X a NR- I ER UECLARA'IION' "� BUILDING PERMIT
o A INFORMATION
E:
;a. I- 1 hereby affirm'that I am exempt from the Contractor's License MISC.- REFER TO ORD
Ru0< Law for the following ,.,.a,(Sec.7031.5,Business and Professions PERMIT ISSUANCEVALUATION $/FT.
Code:Any city or county which requires a permit to construct,alter, 10.00
IS
fS Q p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
0 W requires the applicant for such permit to file a signed statement that TOTAL
e w m u he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
rZ> Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i
at Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE 'U
Mm-$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ag -. by any applicant fora permit subjects the applicant to a civil penalty ALTER-DRAIN (EA.) 5.00
of not more than five hundred dollars($500).}
❑. 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is net
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5,00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
'cuts are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement Is sold within one year of completion, the owner- r
builder will have time burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale.). RES IND CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.0011 ❑ E]licensed contractors to construct the project El Q
(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:'file Contractor's License Low does not apply -to an owner of property who builds or improves thereon,;and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts nor such projects with a contractor(s)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATERPAW
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREJAWGEC4.111987 5.00 -
hereby affirm that I have u certificate'of consent to self-insum, -
r acorn c s'C,.Pen io 1 rasa a ,r a peri icd ZONING- ENG.SITE NO.
C c 0 .C.). l• AU Ino
icy n
Ce till copy is to yf ism • FIRE SPRINK ENERGY T-24
Z 0 ❑ Certifie i 0 t 11 cit 'ns ec di s MISC.- REFER TO ORD. Y[:JNQ YE] N[D
Applicant
~ rn PERMIT ISSUANCE 10.00 s
LU - CERTI'I ATF.OP EXEMPTION FROM WORKERS' ZONE A.L.U.C.
W OMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
C' (This sectio, red not be completed if the permit is for one TOTAL V N� V 0 Nth
O hundred dollar ( 1001 or less.) . . m
I certify that n the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued.I shall ml employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California. -
Date Applicant BUILDING
a '
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
ALTER ORADD TO MECH. 5.00
emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK,'
provisions of the Labor Code, you must forthwith comply with U FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address - HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING IQ,•"1C/
r
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives ec this city to enter upon the BOILER-COMP(Over 100,000 BTUl SEE FEE SCH. _ MECHANICAL
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of - MISC.- REFER T ORD.
Cupertino ,oinat Ilabililie judgments, costs and expenses which CONST:TAX
may in a y way accr a ainst said City in consequence of the PERMIT ISSUANCE 10.00
g(anting o lh s pern'C i ECH.CONT. - LIC.N CH. It
TA` TOTAL
Signature of pelican[Co rac[ r ate - �w.�1
OFFI COPY - U